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HIV Nutrition& Health Benefits

Jenn Messina, RDHIV/AIDS Program

St. Paul’s Hospital, Vancouver November 6th, 2014

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Outline

Personal intro

HIV in Canada

Nutritional issues in HIV

Asymptomatic & symptomatic infection

Provincial health benefits

Resources and good articles

Questions

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Personal Introduction

UBC Integrated Internship Graduated UBC in 2007 Currently working in the Immunodeficiency Clinic,

St. Paul’s Hospital, Outpatient Clinic Worked in HIV nutrition since 2010 B.C. Centre for Excellence in HIV/AIDS Care UBC Clinical Instructor for UBC Land and Food

Systems

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HIV and Canada In Canada, prevalence of HIV has risen from an

estimated 64,000 in 2008 to 71,300 in 2011 (an 11.4% increase)

An estimated 2250-4100 new HIV infections occur in Canada each year

In 2012, 2062 new cases were reported; the lowest recorded since 1985

The overall new infection rate among Aboriginal people was 3.5 times higher than among the non-Aboriginal population in 2011

Stats Canada http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.ph

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Nutritional Issues Malnutrition and wasting Loss of appetite Gastrointestinal complications Side effect of medications Metabolic abnormalities Dental issues Mental health challenges Disordered eating Addictions Socioeconomic factors- food insecurity Special needs groups: pregnancy, children,

adolescents

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HIV Nutrition Assessment Anthropometrics:

Height, weight, BMI, weight history Biochemical: immune status, lipid profile, fasting

blood sugar, renal status, nutritional labs, bone density (if available)

Clinical: Patient medical history, medications, social history

Diet history: Intake of key nutrients e.g. energy, protein, fat, fibre,

calcium, vitamin D Knowledge, beliefs Allergies, intolerances Supplement intake Physical activity Food security Food/support resources

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Symptomatic & Asymptomatic HIV Infection

Symptomatic HIV infection: Fever Opportunistic infections, e.g. Pneumocyctis carinii

pneumonia, (PCP), cytomegalovirus (CMV), and Mycobacterium avium complex (MAC)

Oral thrush Weight loss

Usually CD4+ T helper cells <200

Asymptomatic infection: a phase of chronic infection which the person does not display symptomsUsually CD4+T helper cells >200

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Symptomatic HIV Infection

HIV Associated Weight Loss

Inadequate nutrient intake Oral and upper GI symptoms Anorexia Psychosocial Malabsorption

Altered metabolism Uncontrolled HIV infection AIDS defining illnesses Hormonal deficiencies, cytokine abnormalities

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HIV Wasting Syndrome

HIV Wasting: Infection induced cachexia characterized by inappropriate catabolism of skeletal or other lean proteins

Centre for Disease Control definition: Involuntary weight loss >10% (of baseline

body weight) associated with either chronic diarrhea (two or more loose stools per day for

≥1 month) or chronic weakness and documented fever for ≥1 month

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Symptomatic HIV InfectionCaloric recommendations: 20 - 30% higher than non-infected person with

same age, sex, physical activity to maintain weight

Affected by age, activity level, HIV status, nutritional status, infection, comorbidities, etc.

Initiation of anti-retroviral therapy may also increase energy needs as the individual transitions to a anabolic state

Metabolic cart is the gold standard

Protein recommendations: 1.5 - 2 g protein/kg/day Needs to be individualized

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Metabolic Cart

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Symptomatic HIV: Recommendations

HIV control and treat concurrent infections Addressing psychosocial factors, depression Diet counseling:

Symptom management of GI side effects High calorie, high protein diet Homemade/commercial nutrition supplements Nutrition support (tube feeding) in hospital may be

needed Address food security, community resources, funding,

connect with outpatient RD as needed (if in hospital)

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Asymptomatic HIV: Recommendations

Caloric recommendations: 10% higher than non-infected person with

same age, sex, physical activity to maintain weight Affected by age, activity level, HIV status,

nutritional status, infection, comorbidities, etc.

Protein recommendations 1.0 - 1.2 g protein/kg/day when stable Needs to be individualized

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Asymptomatic recommendations

•Nutrient rich, balanced diet

•Individual energy, protein, micronutrient needs

•Food and water safety

•Encourage exercise

•Ensure food security

•Address any nutritional issues identified

•Consider social factors affecting healthy eating

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Micronutrients

HIV is a chronic inflammatory condition that increases oxidative stress

Adequate vitamin and mineral intake important in optimizing immune function and to delay HIV disease progression

Literature suggests micronutrient deficiencies still occur; commonly low include vitamin A, vitamin B6, vitamin B12, selenium, zinc, iron and thiamine...

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Micronutrients

Ensure meeting minimum micronutrient requirements for age, gender, special conditions

Low serum micronutrient levels associated with increased risk of mortality

Increased risk for deficiency with advanced disease, low CD4, persistent diarrhea, unexplained weight loss

Other factors: food insecurity, dentition, special diet needs

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Metabolic Complications with HIV

Overweight and obesity

Dyslipidemia

Insulin resistance

Reduced bone density

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Weight Management, Dyslipidemia and Insulin Resistance

Clients living longer, developing medical conditions related to aging, medications, lifestyle

In urban, outpatient clinic 48% of those living with HIV are overweight/obese (Messina, Barron & McCall, 2014)

Therapeutic lifestyle and diet are the first line strategy

Traditional approaches to assist with weight management, dyslipidemia and hyperglycemia should be initiated

Dietitian counselling works best if it is regular and sustained

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Bone Health: Screening, Prevention & Treatment HIV positive people at higher risk

for osteopenia and osteoporosis, cause is multifactoral

Assess Determine if risk further increased

with traditional risk factors i.e. menopause, underweight/obese, medications, diet

Prevention Adequate calcium and vitamin D

depends on age Maintain healthy body weight

Nutrient treatment 1000-1200 mg calcium 1000-2000 IU vitamin D

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What is Food Insecurity?

Many definitions: “the limited or uncertain availability of nutritionally adequate,

safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways” (Anema, 2009)

A food insecure individual may have one or several characteristics

-Insufficient food quantity-Limited diversity of food groups

-Poor food safety-Feelings of hunger or anxiety regarding food access

-Procurement of food in socially unacceptable manners

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Poverty in B.C. B.C. has the highest poverty rate in

Canada 12% of British Columbians unable to meet

their basic needs Vancouver Coastal Health (our region)

highest food costs in province 90,193 people used the food bank

between 2010-2011, 15.5% increase since 2008

Dietitians of Canada. The cost of eating in BC, 2011

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Food Security in those with HIV/AIDS in B.C.

Study in B.C. 1998-1999 found 48% of people on ART food insecure, 21% indicate food insecurity with hunger (Normen et al. 2005)

Recent study in B.C. 2007-2008 found 70% of people on ART food insecure (Anema et al., 2011)

Food insecurity 5-9x higher in people living with HIV than general population

In B.C. 64% of HIV-infected IVDU reported frequent hunger (Anema et al., 2009)

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Factors Correlated to Food Insecurity

Female gender Living with children Poverty Unemployment Unstable housing Lack of health insurance Drug use Recent incarceration Impaired physical or mental health

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Food Insecurity and HIV

Food insecurity linked with Increased behavioral risk of HIV disease

transmission Poor antiretroviral therapy access, adherence,

pharmacokinetic effectiveness Reduced baseline CD4 count, incomplete

virologic suppression, and decreased survival (Weiser et. al., 2011, Anema et al. 2009)

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Ministry of Social Development (MSD)

Provincial Nutrition Programs

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Types of Health Supplements Diet Supplement (also known as ‘Diet Allowance’)

Short Term Nutritional Supplement Monthly Nutritional Supplement Other Health Supplements

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Diet Supplements

Diet supplements assist clients to meet costs associated with an unusually expensive therapeutic diet that is required as a result of a specific medical condition or a special dietary need.

A diet supplement may provided for a maximum of 12 months for acute (short-term) conditions and 24 months for chronic (ongoing, recurring, long-term) conditions

Eligibility: For those on MSD income assistance & disability assistance

http://www.eia.gov.bc.ca/mhr/hsp.htm

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Diet SupplementsMonthly Allowance:

$10: Restricted sodium diet $35: Diabetes $30: Kidney dialysis $40: High protein diet (plus $30 towards the purchase

of a blender) $40: Gluten-free diet $40: Dysphagia (plus $30 towards the purchase of a

blender) $40: Ketogenic diet $40: Phenylalanine diet $50: Cystic fibrosis

Note: If client has multiple medical conditions- highest amount ‘trumps’ and only 1 diet

supplement will be given

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Diet SupplementsFunding for high-protein diets is available for

individuals who need additional nutritional support and have been diagnosed with:

Cancer (requiring nutritional support during radiation, chemotherapy, surgical cancer therapy)

Chronic inflammatory bowel disease Crohn's disease Ulcerative colitis HIV/AIDS, chronic bacterial infection and tuberculosis Hyperthyroidism Osteoporosis Hepatitis B or hepatitis C

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/policy.html

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Diet Supplements

To be eligible for a diet supplement, recipients must provide written confirmation of the need for the diet supplement from a medical practitioner, nurse practitioner or from a dietitian who is registered with the College of Dietitians of British Columbia

Diet allowance form available through MSD

Letter can also be done and include: the specific medical condition the diet required expected duration of need

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/faqs.html

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Diet SupplementsHIV/AIDS ProgramSt. Pauls Hospital 1081 Burrard StreetVancouver, B.C.

To Whom It May Concern at the Ministry of Social Development:

Re: Jane SmithDOB: 1/1/1951

My client is HIV positive and requires a high protein diet to help improve nutritional status. Please provide the $40 High Protein Diet Supplement and the initial $30 for purchase of a blender. She will need this diet supplement for 2 years, the maximum allowable time for a chronic condition as she will require this diet as long as she is living.

Sincerely,

Jenn Messina, CDBC #1046Clinical Dietitian604-682-2344 ext 62641

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Short-term Nutrition Supplement Nutritional supplements may be for those

who need additional calories above a regular diet to recover from surgery, severe injury, serious disease, or the side effects of medical treatment

Eligibility: for those on MSD income assistance & disability assistance

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/nutsupp/

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Short-term Nutrition Supplement To be eligible for a nutritional supplement, recipients must

provide written confirmation of the need from a medical practitioner or nurse practitioner

Include: The diagnosis The reason the product is required The name of the product required, the amount of product

required and the expected duration of need (up to a maximum of 3 months)

Letter must confirm acute, short-term need to prevent critical weight loss

For those on MSD income assistance & disability assistance, but NOT getting Monthly Nutritional Supplement (MNS)

http://www.healthlinkbc.ca/healthyeating/bc-nutrition-programs.html

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Short-term Nutrition Supplement

To whom it may concern at the Ministry of Social Development, Re: John SmithDate of birth: 1/1/1951

I am writing as the dietitian for the Immunodeficiency Clinic where John Smith attends for his medical care. John is being followed by the dietitian due to malnutrition and weight loss due to his advanced lung cancer with bone metastasis. This person is also HIV positive and on anti-retroviral therapy for immune reconstitution and viral suppression. John has lost 7.6kg over the past few months, 12% of total body weight, and has visible muscle wasting. His BMI is low at 18.2. Weight loss occurred during his radiation therapy for his cancer and he has had ongoing poor appetite, nausea and weight loss after this therapy has been completed. He is at ongoing high nutrition risk due to upcoming chemotherapy cancer treatment.

He urgently requires 3 bottles of Ensure Plus daily for 3 months to optimize his oral intake, prevent further weight loss, malnutrition, and muscle wasting. Malnutrition and unintentional weight loss increase the risk of morbidity and mortality in HIV positive people.

Please call me with any questions or concerns. Thank you.

Jenn Messina, Clinical Dietitian Dr. Sarah StoneCDBC #1046

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Monthly Nutritional Supplement

“The Monthly Nutritional Supplement is monetary allowance to financially assist those who have a severe medical condition causing a chronic, progressive deterioration of health with symptoms of wasting. This supplement is intended to prevent imminent danger to the person’s life by providing essential, specified items to supplement regular nutritional needs”

Eligibility: for those on MSD Disability Assistance ONLY

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Monthly Nutritional SupplementHow to Apply: Client needs to pick up “Monthly Nutritional

Supplement Application form” from MSD(blank forms NOT accepted)

MSD needs to complete part A Client needs to sign part B RD/MD/NP completes part C

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Monthly Nutritional SupplementRefer to Blank MNS form: Written confirmation by the

recipient’s medical practitioner or nurse practitioner is needed to confirm

1) The person has a severe medical condition causing a chronic, progressive deterioration of health. List conditions and description as needed

Examples: 1) Hepatitis C with severe liver cirrhosis2) Mental Health Challenges: anxiety, depression, and bipolar3) Poor dentition: requires extensive extractions and to be fit for dentures

2) As a direct result of the condition, applicant is being treated for chronic progressive deterioration of healthExamples:

1) HIV positive on antiretroviral therapy for immune reconstitution and viral suppression

2) Followed by psychiatrist and mental health team and is on mood stabilizing medication

3) Hepatitis C positive with moderate cirrhosis and on hepatitis C treatment

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/mns/policy.html

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Monthly Nutritional Supplement3) As a result of this deterioration of health, the person displays two or more of the following symptoms:

-malnutrition -underweight status -significant weight loss -significant muscle mass loss -significant neurological degeneration -significant deterioration of a vital organ -moderate to severe immune suppression

Describe with as much detail as possible e.g. time frames, % body weight loss, visible signs of wasting……..

Monthly Nutritional Supplement5) Vitamins and Minerals are only available to alleviate one or more symptoms in question 3 (usually malnutrition and immune suppression)

Tips: Be specific! Look up disease state in PEN to see what nutrients are

commonly deficient and mention these If the person shows any signs of deficiency e.g. low B12/iron, etc.

mention these Mention any increased requirements e.g. vitamin D for people over 50

or folic acid for women of childbearing age If HIV positive can list that adequate micronutrient intake is essential

to optimize immune system and prevent potentially life threatening opportunistic infections

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6) Nutritional Items: Medically essential and need to provide caloric supplementation to a regular diet. Relate back to symptoms in question 3.

Tips: Need to specify nutritional items such as Ensure/Boost or

protein powder If you put “High protein diet with adequate fruits,

vegetables....” it will be denied Often I put the client would ‘benefit from’ certain nutritional

items Leave the ‘duration of need’ open ended if you aren’t sure the

time frame they may need items for

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Monthly Nutritional SupplementMore tips and tricks for a successful form

Ask clients to take some ownership by picking up form

Make sure to discuss the form first with the person who will consign MD/NP, they take a lot of time!

Don’t ‘overpromise’ Clients often get upset if you ‘won’t help them’ by

just not filling it out, show them form and go through point by point if ineligible

Leave the acronyms out of it

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Monthly Nutritional Supplement

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First NationsSome bands will cover a short-term supply of Ensure/Boost Individual bands vary with coverage, speak with health

department of band department CONFIDENTIALITY

For Status First Nations: For tube feed formula /supplies complete a detailed letter with tube

feed formula, equipment, etc. Physician to review and co-sign and fax to local pharmacy. Pharmacy will then fax ‘letter of exception’ for First Nations Health Authority which MD will need to complete.Overview online First Nations Health Authority Health Benefits Programhttp://www.fnha.ca/ Phone: 604.693.6500Toll free: 1.866.913.0033Fax: 604.913.2081

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ResourcesCATIE: www.catie.caPosition Statement ADA HIV NutritionThe Body: www.thebody.caMinistry of Social Development:

http://www.gov.bc.ca/hsd/AIDS Vancouver: www.aidsvancouver.orgPositive Living BC:

www.positivelivingbc.orgDIAC (Dietitian’s in AIDS Care) Practice

Group

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Good ArticlesGeneral HIV Nutrition Position of the American Dietetic Association: Nutrition Intervention and Human Immunodeficiency Virus Infection (201). Journal of

the American Dietetic Association, 110 (7): 1105-1119. World Health Organization. (2003). Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation.

Geneva, Switzerland. Wasting Ockenga, J. et al. (2006). ESPEN guidelines on enteral nutrition: wasting in HIV and other chronic diseases. Clinical Nutrition, 25:

319-329. Mangili, A., Murman, D., Zampini, M, and Wanke, C. (2006). Nutrition and HIV infection: review of weight loss and wasting in the era

of Highly Active Antiretroviral Therapy from the Nutrition for Healthy Living Cohort. Clinical Infectious Diseases, 42: 836-842. Gastrointestinal issues Wilcox., C.M. & Saag (2008). Gastrointestinal complications of HIV infection: Changing priorities in the HAART era. Gut, 57: 861-870. HIV Metabolic Syndrome Amorosa, V., et al. (2005). A Tale of 2 Epidemics. Journal of Acquired Immune Deficiency Syndrome, 39(5): 557-561. Jacobson, D.L., et al. (2006). Incidence of Metabolic Syndrome in a Cohort of HIV-Infected Adults and Prevalence Relative to the US

Population (National Health and Nutrition Examination Survey). Journal of Acquired Immune Deficiency Syndrome, 43(4): 458-466. Hasse., B. et al. (2011). Morbidity and Aging in HIV-infected persons: the Swiss HIV cohort study. Clinical Infectious Diseases: 1-10. Messina, J., McCall, J. & Barron, A. (2014). Overweight and Obesity Status in an Urban Canadian HIV Outpatient Population.

Journal of the Association of Nurses in AIDS Care.Osteopenia/Osteoporosis McComsey., G.A. et al. (2010). Bone Disease in HIV Infection: A practical Review and Recommendations for HIV Care Providers.

Clinical Infectious Diseases, 51 (8): 937-946. Yin., M. & Stein, E. (2011). The effect of antiretrovirals on vitamin D. Clinical Infectious Diseases, 52 (3): 406-408. Food Insecurity Anema, A. et al. (2009). Food Insecurity and HIV/AIDS: Current knowledge, gaps and research priorities. Current HIV/AIDS Reports,

6: 224-231. Anema, A. et al. (2011). High prevalence of food insecurity amoung HIV-infected individuals receiving HAART in a resource-rich

setting. AIDS Care, 23(2), 221-230. Cost of Eating in British Columbia. (2011). Dietitians of Canada. Normen, L. et al (2005). Food insecurity and hunger are prevalent among HIV-Positive individuals in British Columbia, Canada.

Journal of Nutrition, 135: 820-825. Weiser, S. D., Young, S. L., Cohen, C. R., Kushel, M. B., Tsai, A. C., Tien, P. C., … Bangsberg, D. R. (2011). Conceptual framework

for understanding the bidirectional links between food insecurity and HIV/AIDS. American Journal of Clinical Nutrition, 94(suppl), 1729S-39S.

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Acknowledgements

Alena Spears, HIV RD at St. Paul’s 10C Clients of 10C, IDC, and Providence Crosstown

Clinic Julie Kille, Operations Leader, Scott Harrison

Program Director

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Questions?

Contact: jmessina@providencehealth.bc.ca